POMONA, CA - Federal inspectors documented dangerous bathroom conditions at Country Oaks Care Center that posed health and safety risks to residents with vulnerable respiratory conditions.
Extensive Bathroom Deterioration Documented
During a March 3, 2025 inspection, surveyors found multiple hazardous conditions in a shared bathroom used by four residents. The bathroom showed signs of significant deterioration and potential contamination that had been left unaddressed by facility maintenance staff.
Inspectors documented black substances on both corners of the toilet and along the baseboard. The baseboards on both sides of the toilet had warped from apparent water damage. Around the water shut-off valve, brown substances were present alongside cracked and peeling wall areas.
The bathroom floor presented safety hazards with a 3-inch crack containing a 1/4 inch groove in the tile. The safety grab bar, designed to prevent resident falls, had cracked and peeling plaster with an exposed screw where it attached to the wall.
Additional deterioration was found around the bathroom sink, including a 3-inch crack with black substance where the sink met the wall. Under the sink and around plumbing access points, brown substances were present along with more cracked and peeling plaster.
Maintenance System Failures
The facility's maintenance logs from January 2024 through December 2024 showed no documented repairs for the problematic bathroom, despite the extensive deterioration. The logs also failed to list this bathroom as needing any repairs.
Review of maintenance checklists from December 2024 through February 2025 revealed that no bathrooms were included in routine maintenance inspections, representing a systematic oversight in facility maintenance protocols.
When confronted with the bathroom conditions on March 5, 2025, the Maintenance Supervisor acknowledged the conditions "pose a hazard to the health of the residents" and were "not home-like for the residents."
Health Risks for Vulnerable Population
The deteriorated bathroom conditions presented particular risks for the residents who used the facility. All four residents sharing the bathroom had been admitted with respiratory diagnoses including chronic obstructive pulmonary disease (COPD) or chronic respiratory failure with hypoxia.
COPD is a chronic lung disease that causes breathing difficulties, while hypoxia occurs when blood oxygen levels drop dangerously low. Residents with these conditions face heightened vulnerability to environmental contaminants and poor air quality.
Black and brown substances found throughout the bathroom likely indicate mold or bacterial growth, which can trigger respiratory symptoms and complications in patients with compromised lung function. Exposure to such contaminants can worsen breathing difficulties and potentially lead to serious respiratory infections.
The cracked surfaces and damaged areas create environments where harmful microorganisms can proliferate, particularly in moisture-rich bathroom settings. For residents already struggling with chronic respiratory conditions, such exposure represents a significant health threat.
Safety Hazards Beyond Health Concerns
The physical deterioration created multiple fall risks for residents. The exposed screw on the grab bar could cause injury if residents relied on it for support. The cracked floor tile presented a tripping hazard that could result in serious injuries for elderly residents with mobility challenges.
Nursing home residents face higher fall risks due to medications, medical conditions, and age-related factors. When safety equipment like grab bars becomes compromised, the risk of serious injury increases substantially.
Regulatory Standards Violated
Federal regulations require nursing homes to maintain safe, sanitary, and homelike environments for residents. The facility's own policies emphasized this commitment, stating they would "provide a safe, clean, comfortable and homelike environment" and maintain "a sanitary, orderly and comfortable environment."
The documented conditions represented clear violations of these standards. The facility failed to implement adequate maintenance inspection protocols and allowed hazardous conditions to persist without remediation.
Facility Response and Accountability
Following the inspection, the Maintenance Supervisor committed to beginning "all repairs immediately." However, the extent of deterioration suggested these problems had developed over an extended period without proper attention.
The systematic failure to include bathrooms in routine maintenance checklists indicated broader issues with facility oversight and quality assurance processes. Such oversights raise questions about what other maintenance issues may have been overlooked throughout the facility.
Industry Context and Prevention
Proper maintenance protocols in nursing homes typically include regular inspections of all resident areas, particularly high-moisture environments like bathrooms where deterioration can occur rapidly. Effective programs identify and address minor issues before they become significant hazards.
For residents with respiratory conditions, environmental quality becomes even more critical. Facilities must maintain vigilant oversight of air quality, moisture control, and surface cleanliness to protect vulnerable populations from preventable health complications.
The inspection findings at Country Oaks Care Center demonstrate the importance of comprehensive maintenance programs and regular oversight to ensure resident safety and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Oaks Care Center from 2025-03-06 including all violations, facility responses, and corrective action plans.
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